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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: PLAZA LIQUOR'S 4 2 <br />1 Date of Testing: 10/27/09 <br />Facility Address: 2420 W. TURNER RD. LODI, CA 95242 <br />Facility Contact: TOM <br />Phone: 209-369-1960 <br />Date Local Agency Was Notified of Testing :9/10/09 <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 nd Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ® Zane A. Nim -no ❑ David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />l Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 11 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, H2O <br />Equipment Resolution: 1/16" <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 87 <br />2 91 <br />3� DIESEL <br />4 <br />Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />®Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />❑ Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />11 <br />14 <br />Bucket Depth: <br />12 <br />12 <br />11 <br />Wait time between applying <br />vacuum/water and start of test: <br />Test Start Time (Ti): <br />1030 <br />1030 <br />1030 <br />Initial Reading (Ri): <br />11 1/8 <br />11 3/4 <br />9 1/2 <br />Test End Time (TF): <br />1130 <br />1 130 <br />1130 <br />Final Reading (RF): <br />11 1/8 <br />11 3/4 <br />9 1/2 <br />Test Duration (TF — Ti): <br />HR <br />HR <br />HR <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or _ <br />Criteria: <br />-- <br />Test Result: ® Pass ❑Fail <br />Pass ❑ Fail <br />E Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: — Date: 10-27-09 <br />1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />